Easing The Pain

Pain centers throughout the state treat patients with back problems, arthritis, migraines or cancer using a combination of medications, physical therapy, interventions and education.

Mary Anne Dunkin

when all else fails: Dan C. Martin, MD, director of the Pain Medicine Program at the Medical College of Georgia in Augusta

Phil Jones

As unpleasant as it can be, pain has its place. It’s nature’s way of letting us know there’s a problem – whether a stubbed toe or a heart attack – that requires attention.

But such pain – acute pain – usually resolves once the problem causing it is treated. When pain persists past the problem that caused it, or the cause of pain cannot be found, pain becomes the problem. And it’s a costly one – translating into $100 billion per year in the form of medical bills and lost work days, according to the American Pain Society, a research and advocacy organization for patients with pain.

While pain has existed as long as life on the planet, experts say it has only in recent years gained acceptance as a problem rather than just a symptom. “I think people are more receptive to the idea of treating pain more as a disease unto itself instead of a symptom,” says Marion Lee, MD, a board-certified anesthesiologist who left an anesthesia practice in Cordele to start the Pain Center at Affinity Health Group in Tifton in January 2006.

“If pain lasts for three months – some people say six months or longer – at that point it becomes chronic pain and at that point it needs to be treated,” Lee says.

Fortunately, the outlook for people in pain is improving readily, thanks to the increased recognition of pain, the development of new therapies (and some changes in thinking on some existing ones) and the existence of clinics such as Dr. Lee’s that focus solely on relieving pain and improving function.

Today, in Georgia, most hospitals offer a wide range of services, if not a dedicated center, to help people with chronic pain. Some focus on specific types of problems (such as back pain) or treatments (surgical procedures or injections). Others use a multidisciplinary approach to treating a wide range of pain problems, including migraines, arthritis, back pain, shingles, cancer pain and diabetic neuropathy – pain sensations caused by diabetes-related nerve damage.

While a few people seek help from a pain center early in the pain process, for most a visit to a such a center comes after pain has gone on a while, and often treatments have had less than satisfying results, says Dan C. Martin, MD, director of the Pain Medicine Program at the Medical College of Georgia in Augusta. Of the patients he sees, 20 to 30 percent have had surgeries, he says, and most have “failed everything that is non-surgical.”

Yet with the appropriate treatment or combination of treatments, he has found, even those who have “failed everything” can get some relief.

There are pain centers throughout the state. American Pain Society spokesperson Chuck Weber advises asking your family physician for a referral or checking with local hospitals to find out what they offer. Specific areas of expertise and services vary, but most will offer – or direct you to – at least some of these: medication, physical therapy, interventions and psychological approaches.

Medication

Medication has long been a cornerstone of pain treatment. But while narcotic, or opioid, pain medication was once reserved for patients recovering from surgery or dealing with cancer, increasingly doctors are prescribing it for chronic, noncancer pain. If administered properly, such drugs can be a useful part of treatment for chronic pain, Weber says.

But doctors say the potential for dependency and abuse exists, so they still use them sparingly and require monitoring for patients who use them. “Most patients, if they require opioids, I will see them on a monthly basis,” Dr. Lee says.

Even so, Dr. Lee is careful about whom he prescribes the drugs for. Opioids – at least while your body is becoming used to them – can impair reflexes or cause drowsiness, he says. “If [the patient] is driving a school bus or working with dangerous chemicals, we have to talk about [how] this may not be appropriate for you. The patient may not have even thought about it, and it is my responsibility to make sure I do not put them in harm’s way or the people who rely on them in harm’s way.”

When patients need medication long-term or need quick relief, doctors may look beyond oral medication options. One effective option, particularly for cancer patients, is a drug infusion pump, which delivers narcotic medications such as morphine or hydromorphone (Dilaudid ®) in very small doses directly into the spinal fluid, thereby minimizing side effects – sedation or constipation – that can occur with oral narcotics, Dr. Lee says.

Other forms, including nasally administered analgesics, are being studied, says Vincent Galan, MD, director of the Pain Center at Southern Regional Medical Center in Riverdale. Through his involvement in pharmaceutical research, Dr. Galan is able to offer his patients access to some of these drugs before they are mass marketed.

One promising option, which is in phase III trials (the last stage of clinical testing before a drug’s approval by the FDA) is nasal fentanyl. “Fentanyl is a medication that we use in the operating room intravenously,” Dr. Galan says. “When given nasally, it is appropriate for people who are nauseated.” Another benefit is that it works quickly. Unlike oral medications, which typically take 30 to 45 minutes to produce noticeable pain relief, fentanyl, administered nasally, starts to work in five minutes and achieves its full effect in 15 to 20 minutes, he says.

In some cases the best medications for pain are those not developed for pain. Medications such as antidepressants, muscle relaxants and anti-anxiety medications are often helpful for problems such as low back pain or fibromyalgia, a common and often debilitating condition characterized by widespread pain and fatigue.

Physical Therapy

Many people with chronic pain, particularly musculoskeletal pain, benefit from physical therapy, which may include exercises to lessen pain and improve function, and hands-on therapies such as massage to ease tense muscles.

Other physical therapy methods include ice packs or heat in the form of heating pads, hot water bottles and warm baths or showers. Deep heat may be administered by ultrasound to relax tight tissues causing pain and stiffness.

For lower back pain or joint pain, physical therapists often administer transcutaneous electrical nerve stimulation (TENS), a therapy in which a small battery-operated device delivers a mild electrical current through an electrode placed on the skin over the source of pain. This current masks pain by stimulating nerves in the area and creating a mild tingling sensation.

Although some pain centers focus on physical therapy or offer such services on the premises, others refer patients for therapy as an adjunct to other pain therapies. For some, physical therapy is a prerequisite to other therapies. “We believe that if you have a musculoskeletal problem you should have physical therapy before you have any interventional procedure,” Dr. Galan says.

Interventions

Pain centers may offer a number of interventional procedures to ease different types of pain.

For nerve pain – for example, pain caused by a nerve pinched where it exits the spinal column, post-herpetic neuralgia (pain that persists after shingles) or pain that is caused by diabetes-related nerve damage – many patients achieve relief through interventions to calm or block the painful nerves.

Probably the most common of these are the lumbar epidural steroid injection and cervical epidural injection, says Janice Murphy, registered nurse and department coordinator of the Northside Hospital pain treatment centers in Atlanta, Alpharetta and Forsyth, which specialize in injection procedures. To administer these injections, the physician puts a steroid medication directly into the spinal column to halt inflammation of the lower back (lumbar) or neck (cervical). The procedure is useful not only for pain in the back or neck itself but for pain that radiates down the legs or arms.

If particular nerves can be pinpointed, doctors can often do a nerve-block injection specific to the nerve rather than a general epidural steroid injection, Murphy says. The injection contains both a local anesthetic and a steroid. If placed appropriately, the anesthetic provides immediate relief for the patient. The steroid starts to take effect two or three days later.

Sometimes heat or electrical stimulation, rather than drugs, is used to block nerve impulses. In radiofrequency treatments, clinicians place a needle electrode near the nerves that serve a targeted area – for example, the sensory nerve that goes to the hip or knee or down the leg or joints of the spine, Dr. Martin says. Using a special X-ray called fluoroscopy to guide the needle, the doctor does a diagnostic injection first with a local anesthetic. “After that we do the radiofrequency treatment of the same nerve,” he says. “The heat created by the treatment cuts off pain messages.”

The procedure can be done no more than twice per year, says Dr. Martin. “We have about 150 patients a year that get radiofrequency treatment and then go on their merry way for six, eight or 12 months and then ask to have it repeated. Most of the time they are not on any medicine at all.”

Electrical stimulation of the spinal cord is done with an implantable, battery-operated medical device that delivers a mild electrical current through electrodes placed in the spine. The current creates a tingling sensation that alters the patient’s perception of pain. For many patients, the results are satisfying, says Dr. Galan, who has offered this intervention to patients since 1991.

“Patients get relief and get off narcotics,” he says. “I have had patients who haven’t even come back for their follow-ups, or they have come back maybe once to change the parameters of their neurostimulation, and I haven’t seen them since.”

Patients who have benefited most from this treatment, Dr. Galan says, include those with failed back surgeries, spinal stenosis, chronic abdominal pain, diabetic neuropathy, pelvis pain and interstitial cystitis (a painful bladder condition).

Psychological Approaches

Pain is undeniably a physical problem, but the brain is where you perceive pain. Increasingly, scientists and clinicians are acknowledging that the brain and its psychological and emotional process strongly influence the experience of pain – and they’re gaining a better understanding of how that works. The good news is that counseling and education in psychological techniques can aid in pain relief. Many pain clinics refer patients for psychological counseling, and some offer the services of a psychologist onsite.

“Typically when people are referred to me, the first session is an evaluation,” says Rebecca Jump, PhD, clinical health psychologist specializing in treating pain at the Medical College of Georgia. “I get an understanding of their pain history, their health history, and an understanding of the way pain interferes in various domains of their life and with their function and background on how they are coping. That sort of big picture concept of what that person is dealing with helps me assess how I might be of help to them.”

Many times help starts with education – explaining to patients the relationship between mood and pain and how negative emotions can increase or enhance pain perception, Jump says. When patients become aware of how stress and emotions affect pain, she teaches them exercises to put their bodies in a more relaxed state that serves to ease pain.

Such exercises include: diaphragmatic breathing, or breathing deep into the lungs by flexing the diaphragm; imaging and visualization, or imagining yourself in a pleasant pain-free place; progressive muscle relaxation, or systematically tensing and then relaxing specific muscle groups until the whole body is relaxed; and autogenic relaxation, a more passive technique in which you concentrate on each muscle group as you silently repeat to yourself, “My right arm is heavy, warm and relaxed. My right hand is limp and relaxed.”

“Such techniques are portable and you can use them as you need them,” Jump says. “Once patients practice regularly, the effect and the benefit of the response that they get from using the technique is strengthened, so then it can be really effective in a time that you need it. I encourage people to practice even when they are not stressed or tensed or in pain, just to strengthen that response.”

Aside from teaching relaxation techniques, Jump stresses with her patients the importance of pacing – don’t overdo on good days to make up for time missed on bad days, as well as getting proper sleep and taking time to do something fun.

“A lot of times when people are hurting and frustrated because they are not getting the relief they want or are not able to do the things they used to do, they kind of drift into not doing anything,” she says. But not doing anything leads to focusing on their pain and what they’ve lost, which can make pain worse. Sometimes a little fun is the best medicine.

There are many options for treating pain. The best treatment – or combination of treatments – is highly individual and depends on a number of factors, including the cause of pain, where it is felt and how intense the pain is, Weber says.

“The message is that indeed one size does not fit all and the multidisciplinary approach is the best way to attack all of the forces that influence chronic pain,” he says. With work and patience – and the help of a health professionals – most people can live a normal life.